[Needles] Button Hole Technique

Where can I find more information on this…especially with pics or even better an online video describing it. Are special needles needed?

Hi Gus,

Good for you for wanting to try this. There are no large studies on the benefits of the buttonhole technique, but for years there have been small studies and anecdotal reports that seem to say it can work well for people with fistulas (this can’t be done with grafts).

If you look on the links for this site: ( http://www.homedialysis.org/v1/links/#6) under PD Catheters and Vascular Access, you’ll find some information about the buttonhole technique. There is also more information under Professional Resources at (http://homedialysis.org/v1/resources/index.shtml) under Vascular Access and Buttonhole–including a step-by-step document.

I wish we had an on-line video! I’ve been talking with Medisystems to see if they’d be willing to share the printed info they have, which includes photos, but so far no luck. We’ll keep trying, though, and hopefully some folks who are doing this can write in and tell you more.

Hi y’all,

Medisystems gave us permission to include their terrific step-by-step brochures on how to start and use the buttonhole technique with an A/V fistula. You can view this now under “Types of Home Dialysis>Buttonhole” and you can also download it there and from our Links or Professional Resources sections under Vascular Access and Buttonhole.

Check it out! :smiley:

I just checked it out, thank you both! So it seems this can be done with standard AV fistula needles…now I am gonna exeriment with this…

Yikes! I’m not sure “experimenting” is a great idea–best to find someone who has done this or taught folks how to do it and get some expert advice…

Also, you can START a buttonhole channel with regular, sharp needles, but then once the channel is created, you need to use the blunt, buttonhole needles (made by Medisystems) to avoid changing the channel. So to order those buttonhole needles, you probably need to work with your clinic.

Aha, I better hold off then…my clinic was planning on starting this program but then nothing has been said or started…will remind them…


I’ve been using the buttonhole needling method since switching to more frequent home hemo in August 2001. On a three day a week dialysis schedule (which I was on incenter for 11 years before going home in August 2001) I used the ladder method which meant that I would try to use as much of my fistula as I could, going up and down the fistula and coming in from both sides for both the arterial and venous needles. I suppose it is called the ladder method because if you connected the puncture sites in a certain way, connected the dots, it would look like a ladder.

I like the buttonhole method more than the ladder method. Once the buttonholes are established it hurts less to insert the needles, there seems to be no chance of infiltration and the puncture sites seem to stop bleeding quicker with the dull buttonhole needles than with the sharp standard needles. I have found that having two sets of buttonhole needle insertion sites is better than having just a single pair of insertion sites. For a while I had two venous sites and one arterial but I found that the arterial site never had a chance to scab over when I used it every treatment.

By using my sites every other treatment the sites have a chance to scab over. Then when I remove the scab there is a clear starting point through which to insert the needle. I have just had to reestablish one pair of my buttonhole sites. I traveled for most of the month of July which meant that I had to go back to a three day a week schedule. Well somewhere between Copenhagen and Brussels I let one set of my buttonhole sites heal too much and I could no longer get a dull buttonhole needle inserted. Since returning I have started a new pair of sites and last night I switched from sharp needles to buttonhole needles.

One thing I thought about when selecting the sites for my new buttonholes was picking a spot that would be easy to identify. I picked a spot in a direct line between the new site’s sister site and a freckle/discolored spot. That way I am sure I have the side to side angle of the needle right and I only have to think about the up/down angle. The up/down angle is easy to duplicate stick after stick because I have always used the same angle whether using buttonhole or standard needles.

One other thing I do that I have not seen mentioned is that I use an old style pump-up blood pressure cuff to partially occlude my fistula when inserting the needles. I like using the pressure cuff (as opposed to a tourniquet) because I can pump up the pressure to a point right between my systolic and diastolic blood pressures. This way I know the fistula is partially occluded without being cut off completely.

Lastly I know that many people on dialysis think they could never insert their own needles – well I think that you can. If I can do it you can do it. When I started treatments I could not even look while the tech inserted the needles but with staff encouragement I eventually tried putting one in for myself. I remember at the time thinking self cannulation (needle insertion) involves less discomfort because I was in control, I knew what was coming.

I have met people with all sorts of accesses and varying degrees of grip strength and dexterity who self cannulate. It really comes down to motivation – if you want to do it you can find a way. Sticking a needle into your access does not take much strength, it is a subtle movement, some people hold the needle still and move the arm with the access into the needle. Others like me keep our access arms still and move the needle. I bet anyone thinking of giving self cannulation a try could get some guidance from the best “sticker” at their unit. Just ask what they think about when they set up to put the needle in and talk about how you could do it yourself. You don’t have to try it but give it some serious thought there are many advantages. Then once you develop your cannulation skills you can start thinking about trying the buttonhole method (if your unit makes dull buttonhole needles available). Good Luck,

Can someone give me the number for Medisystems? thanks.

Hi y’all,

Mark, according to the MediSystems website, their toll-free contact number is: (800) 369-MEDI, which would be (800) 369-6334.

Bill–love the blood pressure cuff idea for occluding blood flow to put needles in. I bet it’s a lot less painful than a tourniquet, too.

Hi, Sorry we have been away since 8/5 and just am getting to read some posts.
My husband uses the buttonhole technique. We do nocturnal dialysis 6 nights a week and I put his needles in and watch the machine. I also draw his bloods when it is time. I can not say enough about this technique! We were on vacaion in Florida when he had a mild heart attack and needed quad bi-passes. His surgery was at the Florida Hospital on the day of Charley! We were able to fly back home to upstate NY this past friday and I firmly believe his great recover is due to nocturnal dialysis.! If I can answer any question please let me know.
My e-mail is pc639@verizon.net
Pat :lol:

I’m confused! I’m currently in center, but wanting to do home hemo. I’ve read about the buttonhole method and understand, but at the same time I’ve been told that to prolong the life of my fistula I must have staff rotate the sites and use the entire fistula. They weren’t too good about that at the first unit and I had stenosis at both ends of access, which ended up needing balloon angioplasty done after only 2 1/2 yrs… I have no other options for access, except of course a catheter, so I want to learn as much as I can. Would using the buttonhole method have any effect on the life of the fistula? Lin.

like you I have had my fistula pretty messed up by center staff who believe they have to rotate sites.
I have been using the “buttonhole” technique and it seems to be holding up pretty well, tho I am not on home hemo all that long. it gets easier and easier as you go along, which I think is the “tunnel” developing. I now just try to get the right angle and push the needle in. I use blunt needles which would be very hard to puncture with.
it still hurts but not like cutting through raw flesh. it also stops bleeding a lot faster since there is no cutting involved.
I believe that dialysis center staff are very poorly informed, treat patients like we should be cut out with cookie cutters, and punish us if we don’t conform.

For the last 30+ years dialysis nurses and techs (and probably nephrologists) have been trained that to protect an access you have to rotate sites. This is true for grafts, but the buttonhole technique has been used successfully with some patients wth fistulas for years. Unfortunately, staff are at the lower end of the learning curve and believe that sticking the same place will at best ruin the access and at worst will put the person at risk of serious blood loss if the scab is removed. Staff are starting to hear more about the buttonhole technique at meetings. Those of you that are using it need to be spokespersons for it – with staff and with patients. There is now a special needle that can be used after the tunnel has been formed. The maker of this neede, Medisystems, is a sponsor of Home Dialysis Central. You can click of Medisystem’s logo on the homepage and read about it. Check out Medisystem’s website as well. I hope that with time, more staff (and patients) will learn how to do the buttonhole technique.

Encourage staff that think you must rotate sites with fistulas to read the information posted on Home Dialysis Central about the buttonhole technique. To make any change, people need to have a WIIFM (what’s in it for me). The WIIFM in this case is that if patients stop bleeding faster using the buttonhole technique, in-center nurses and PCTs may have more time between patients or turnaround time may be faster so they can get done earlier in the day. The WIIFM for patients could be less pain, shorter waiting time to get done after dialysis, and hopefully fewer access problems (especially if they stick themselves).

Thanks for the great information Beth. I have very little possibilities when it comes to another acess, and too wanted to know about the method home hemo pts. are using, as you know I’m a wanna be lol I will be mentioning this information to staff, and too discussing it with my new neph. who is super!
Helen, I can count on you to tell it like it is; loved the visual I got. I hope you are back home, happy, and the home hemo is going along smoother. Lin.

Hi y’all!

I’m back, and just wanted to make a quick clarification: although Medisystems has been wonderful about providing permission for Home Dialysis Central to post their terrific info on the buttonhole technique, they are not a corporate sponsor of this site. : )

just wanted to let you know my arterial “buttonhole” has been giving me trouble, enough so that I aborted 2 dialysis attempts because who wanted to change tubing and dialyzer at 10 p.m. and restick myself.
for a few days I used a sharp needle in the same spot and by the 4th attempt I was able to use a blunt.
Lin, you need sharps to start the buttonhole but by the 4th or 5th attempt the site may be ready for blunts. blunts are highly unlikely to cause an infiltration and are much preferred. they hurt less and cause less bleeding too.

Took me more than seven times just to use buttonHole needles…but now it’s a breeze…they just slide ride in!..painless…only gripe is that the clamps are harder to shut than the sharps!!.. :x

For your info, I have my fistula over 20 years now and they’re kinda ballooned… :stuck_out_tongue: …still, buttonhole worked well on it…